|
SPLINT FUNCTIONAL POSITION R/L #A311-RL
|
Facility
|
OP
|
$486.00
|
|
| Hospital Charge Code |
2971300
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$141.52 |
| Max. Negotiated Rate |
$465.00 |
| Rate for Payer: Aetna Commercial |
$454.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$434.68
|
| Rate for Payer: Aetna Managed Medicare |
$141.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$328.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$252.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$242.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$267.88
|
| Rate for Payer: Cash Price |
$145.80
|
| Rate for Payer: Cigna Commercial |
$465.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$282.85
|
| Rate for Payer: Health EOS Commercial |
$449.84
|
| Rate for Payer: HFN Commercial |
$465.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$379.08
|
| Rate for Payer: Multiplan Commercial |
$404.35
|
| Rate for Payer: NAPHCARE Commercial |
$303.26
|
| Rate for Payer: Preferred Network Access Commercial |
$465.00
|
| Rate for Payer: Quartz Beloit One Network |
$247.67
|
| Rate for Payer: Quartz Commercial |
$328.54
|
| Rate for Payer: Quartz Medicare Advantage |
$303.26
|
| Rate for Payer: The Alliance Commercial |
$252.72
|
| Rate for Payer: WEA Trust Commercial |
$277.99
|
| Rate for Payer: WPS Commercial |
$374.37
|
|
|
SPLINT FUNCTIONAL POSITION R/M #A311-RM
|
Facility
|
IP
|
$442.00
|
|
| Hospital Charge Code |
2971144
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$225.24 |
| Max. Negotiated Rate |
$422.91 |
| Rate for Payer: Aetna Commercial |
$413.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$395.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$243.63
|
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Cigna Commercial |
$422.91
|
| Rate for Payer: Health EOS Commercial |
$409.12
|
| Rate for Payer: HFN Commercial |
$422.91
|
| Rate for Payer: Multiplan Commercial |
$367.74
|
| Rate for Payer: Preferred Network Access Commercial |
$422.91
|
| Rate for Payer: Quartz Beloit One Network |
$225.24
|
| Rate for Payer: Quartz Commercial |
$275.81
|
| Rate for Payer: WEA Trust Commercial |
$252.82
|
| Rate for Payer: WPS Commercial |
$340.47
|
|
|
SPLINT FUNCTIONAL POSITION R/M #A311-RM
|
Facility
|
OP
|
$442.00
|
|
| Hospital Charge Code |
2971144
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$128.71 |
| Max. Negotiated Rate |
$422.91 |
| Rate for Payer: Aetna Commercial |
$413.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$395.32
|
| Rate for Payer: Aetna Managed Medicare |
$128.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$298.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$229.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$220.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$243.63
|
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Cigna Commercial |
$422.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$257.24
|
| Rate for Payer: Health EOS Commercial |
$409.12
|
| Rate for Payer: HFN Commercial |
$422.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$344.76
|
| Rate for Payer: Multiplan Commercial |
$367.74
|
| Rate for Payer: NAPHCARE Commercial |
$275.81
|
| Rate for Payer: Preferred Network Access Commercial |
$422.91
|
| Rate for Payer: Quartz Beloit One Network |
$225.24
|
| Rate for Payer: Quartz Commercial |
$298.79
|
| Rate for Payer: Quartz Medicare Advantage |
$275.81
|
| Rate for Payer: The Alliance Commercial |
$229.84
|
| Rate for Payer: WEA Trust Commercial |
$252.82
|
| Rate for Payer: WPS Commercial |
$340.47
|
|
|
SPLINT FUNCTIONAL POSITION R/S #A311-RS
|
Facility
|
IP
|
$460.00
|
|
| Hospital Charge Code |
2971256
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$234.42 |
| Max. Negotiated Rate |
$440.13 |
| Rate for Payer: Aetna Commercial |
$430.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.55
|
| Rate for Payer: Cash Price |
$138.00
|
| Rate for Payer: Cigna Commercial |
$440.13
|
| Rate for Payer: Health EOS Commercial |
$425.78
|
| Rate for Payer: HFN Commercial |
$440.13
|
| Rate for Payer: Multiplan Commercial |
$382.72
|
| Rate for Payer: Preferred Network Access Commercial |
$440.13
|
| Rate for Payer: Quartz Beloit One Network |
$234.42
|
| Rate for Payer: Quartz Commercial |
$287.04
|
| Rate for Payer: WEA Trust Commercial |
$263.12
|
| Rate for Payer: WPS Commercial |
$354.34
|
|
|
SPLINT FUNCTIONAL POSITION R/S #A311-RS
|
Facility
|
OP
|
$460.00
|
|
| Hospital Charge Code |
2971256
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$133.95 |
| Max. Negotiated Rate |
$440.13 |
| Rate for Payer: Aetna Commercial |
$430.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.42
|
| Rate for Payer: Aetna Managed Medicare |
$133.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$310.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$239.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$229.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.55
|
| Rate for Payer: Cash Price |
$138.00
|
| Rate for Payer: Cigna Commercial |
$440.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$267.72
|
| Rate for Payer: Health EOS Commercial |
$425.78
|
| Rate for Payer: HFN Commercial |
$440.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$358.80
|
| Rate for Payer: Multiplan Commercial |
$382.72
|
| Rate for Payer: NAPHCARE Commercial |
$287.04
|
| Rate for Payer: Preferred Network Access Commercial |
$440.13
|
| Rate for Payer: Quartz Beloit One Network |
$234.42
|
| Rate for Payer: Quartz Commercial |
$310.96
|
| Rate for Payer: Quartz Medicare Advantage |
$287.04
|
| Rate for Payer: The Alliance Commercial |
$239.20
|
| Rate for Payer: WEA Trust Commercial |
$263.12
|
| Rate for Payer: WPS Commercial |
$354.34
|
|
|
SPLINT HAND FUNCTIONAL POSITION RT/MED #7091-12-01
|
Facility
|
OP
|
$462.00
|
|
| Hospital Charge Code |
2971170
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$134.53 |
| Max. Negotiated Rate |
$442.04 |
| Rate for Payer: Aetna Commercial |
$432.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$413.21
|
| Rate for Payer: Aetna Managed Medicare |
$134.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$312.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$240.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$230.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$254.65
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cigna Commercial |
$442.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$268.88
|
| Rate for Payer: Health EOS Commercial |
$427.63
|
| Rate for Payer: HFN Commercial |
$442.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$360.36
|
| Rate for Payer: Multiplan Commercial |
$384.38
|
| Rate for Payer: NAPHCARE Commercial |
$288.29
|
| Rate for Payer: Preferred Network Access Commercial |
$442.04
|
| Rate for Payer: Quartz Beloit One Network |
$235.44
|
| Rate for Payer: Quartz Commercial |
$312.31
|
| Rate for Payer: Quartz Medicare Advantage |
$288.29
|
| Rate for Payer: The Alliance Commercial |
$240.24
|
| Rate for Payer: WEA Trust Commercial |
$264.26
|
| Rate for Payer: WPS Commercial |
$355.88
|
|
|
SPLINT HAND FUNCTIONAL POSITION RT/MED #7091-12-01
|
Facility
|
IP
|
$462.00
|
|
| Hospital Charge Code |
2971170
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$235.44 |
| Max. Negotiated Rate |
$442.04 |
| Rate for Payer: Aetna Commercial |
$432.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$413.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$254.65
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cigna Commercial |
$442.04
|
| Rate for Payer: Health EOS Commercial |
$427.63
|
| Rate for Payer: HFN Commercial |
$442.04
|
| Rate for Payer: Multiplan Commercial |
$384.38
|
| Rate for Payer: Preferred Network Access Commercial |
$442.04
|
| Rate for Payer: Quartz Beloit One Network |
$235.44
|
| Rate for Payer: Quartz Commercial |
$288.29
|
| Rate for Payer: WEA Trust Commercial |
$264.26
|
| Rate for Payer: WPS Commercial |
$355.88
|
|
|
SPLINT LMB FINGER FLEXION D #7046-03
|
Facility
|
IP
|
$370.00
|
|
| Hospital Charge Code |
2971021
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$188.55 |
| Max. Negotiated Rate |
$354.02 |
| Rate for Payer: Aetna Commercial |
$346.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$203.94
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$354.02
|
| Rate for Payer: Health EOS Commercial |
$342.47
|
| Rate for Payer: HFN Commercial |
$354.02
|
| Rate for Payer: Multiplan Commercial |
$307.84
|
| Rate for Payer: Preferred Network Access Commercial |
$354.02
|
| Rate for Payer: Quartz Beloit One Network |
$188.55
|
| Rate for Payer: Quartz Commercial |
$230.88
|
| Rate for Payer: WEA Trust Commercial |
$211.64
|
| Rate for Payer: WPS Commercial |
$285.01
|
|
|
SPLINT LMB FINGER FLEXION D #7046-03
|
Facility
|
OP
|
$370.00
|
|
| Hospital Charge Code |
2971021
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$107.74 |
| Max. Negotiated Rate |
$354.02 |
| Rate for Payer: Aetna Commercial |
$346.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.93
|
| Rate for Payer: Aetna Managed Medicare |
$107.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$250.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$192.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$184.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$203.94
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$354.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$215.34
|
| Rate for Payer: Health EOS Commercial |
$342.47
|
| Rate for Payer: HFN Commercial |
$354.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$288.60
|
| Rate for Payer: Multiplan Commercial |
$307.84
|
| Rate for Payer: NAPHCARE Commercial |
$230.88
|
| Rate for Payer: Preferred Network Access Commercial |
$354.02
|
| Rate for Payer: Quartz Beloit One Network |
$188.55
|
| Rate for Payer: Quartz Commercial |
$250.12
|
| Rate for Payer: Quartz Medicare Advantage |
$230.88
|
| Rate for Payer: The Alliance Commercial |
$192.40
|
| Rate for Payer: WEA Trust Commercial |
$211.64
|
| Rate for Payer: WPS Commercial |
$285.01
|
|
|
Splint, long arm applied - Treatments Done
|
Facility
|
IP
|
$451.00
|
|
|
Service Code
|
CPT 29105
|
| Hospital Charge Code |
3025946
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$229.83 |
| Max. Negotiated Rate |
$431.52 |
| Rate for Payer: Aetna Commercial |
$422.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$403.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$248.59
|
| Rate for Payer: Cash Price |
$135.30
|
| Rate for Payer: Cigna Commercial |
$431.52
|
| Rate for Payer: Health EOS Commercial |
$417.45
|
| Rate for Payer: HFN Commercial |
$431.52
|
| Rate for Payer: Multiplan Commercial |
$375.23
|
| Rate for Payer: Preferred Network Access Commercial |
$431.52
|
| Rate for Payer: Quartz Beloit One Network |
$229.83
|
| Rate for Payer: Quartz Commercial |
$281.42
|
| Rate for Payer: WEA Trust Commercial |
$257.97
|
| Rate for Payer: WPS Commercial |
$347.41
|
|
|
Splint, long arm applied - Treatments Done
|
Facility
|
OP
|
$451.00
|
|
|
Service Code
|
CPT 29105
|
| Hospital Charge Code |
3025946
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$171.02 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$422.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$403.37
|
| Rate for Payer: Aetna Managed Medicare |
$171.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$304.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$234.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$225.14
|
| Rate for Payer: Anthem Medicare Advantage |
$171.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$248.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$171.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$171.02
|
| Rate for Payer: Cash Price |
$135.30
|
| Rate for Payer: Cash Price |
$135.30
|
| Rate for Payer: Cash Price |
$135.30
|
| Rate for Payer: Cigna Commercial |
$431.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$171.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$171.02
|
| Rate for Payer: Health EOS Commercial |
$417.45
|
| Rate for Payer: HFN Commercial |
$431.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$636.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$171.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$171.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$171.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$171.02
|
| Rate for Payer: Multiplan Commercial |
$375.23
|
| Rate for Payer: NAPHCARE Commercial |
$256.53
|
| Rate for Payer: Preferred Network Access Commercial |
$431.52
|
| Rate for Payer: Quartz Beloit One Network |
$229.83
|
| Rate for Payer: Quartz Commercial |
$304.88
|
| Rate for Payer: Quartz Medicare Advantage |
$171.02
|
| Rate for Payer: The Alliance Commercial |
$684.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$171.02
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$257.97
|
| Rate for Payer: Wellcare Medicare |
$171.02
|
| Rate for Payer: WPS Commercial |
$347.41
|
|
|
Splint, long leg applied - Treatments Done
|
Facility
|
OP
|
$503.00
|
|
|
Service Code
|
CPT 29505
|
| Hospital Charge Code |
3025945
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$171.02 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$470.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$449.88
|
| Rate for Payer: Aetna Managed Medicare |
$171.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$340.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$261.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$251.10
|
| Rate for Payer: Anthem Medicare Advantage |
$171.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$277.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$171.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$171.02
|
| Rate for Payer: Cash Price |
$150.90
|
| Rate for Payer: Cash Price |
$150.90
|
| Rate for Payer: Cash Price |
$150.90
|
| Rate for Payer: Cigna Commercial |
$481.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$171.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$171.02
|
| Rate for Payer: Health EOS Commercial |
$465.58
|
| Rate for Payer: HFN Commercial |
$481.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$636.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$171.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$171.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$171.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$171.02
|
| Rate for Payer: Multiplan Commercial |
$418.50
|
| Rate for Payer: NAPHCARE Commercial |
$256.53
|
| Rate for Payer: Preferred Network Access Commercial |
$481.27
|
| Rate for Payer: Quartz Beloit One Network |
$256.33
|
| Rate for Payer: Quartz Commercial |
$340.03
|
| Rate for Payer: Quartz Medicare Advantage |
$171.02
|
| Rate for Payer: The Alliance Commercial |
$684.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$171.02
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$287.72
|
| Rate for Payer: Wellcare Medicare |
$171.02
|
| Rate for Payer: WPS Commercial |
$387.46
|
|
|
Splint, long leg applied - Treatments Done
|
Facility
|
IP
|
$503.00
|
|
|
Service Code
|
CPT 29505
|
| Hospital Charge Code |
3025945
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$256.33 |
| Max. Negotiated Rate |
$481.27 |
| Rate for Payer: Aetna Commercial |
$470.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$449.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$277.25
|
| Rate for Payer: Cash Price |
$150.90
|
| Rate for Payer: Cigna Commercial |
$481.27
|
| Rate for Payer: Health EOS Commercial |
$465.58
|
| Rate for Payer: HFN Commercial |
$481.27
|
| Rate for Payer: Multiplan Commercial |
$418.50
|
| Rate for Payer: Preferred Network Access Commercial |
$481.27
|
| Rate for Payer: Quartz Beloit One Network |
$256.33
|
| Rate for Payer: Quartz Commercial |
$313.87
|
| Rate for Payer: WEA Trust Commercial |
$287.72
|
| Rate for Payer: WPS Commercial |
$387.46
|
|
|
SPLINT NITE FOOT LG NS2000-14
|
Facility
|
OP
|
$586.00
|
|
| Hospital Charge Code |
2975028
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$170.64 |
| Max. Negotiated Rate |
$560.68 |
| Rate for Payer: Aetna Commercial |
$548.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.12
|
| Rate for Payer: Aetna Managed Medicare |
$170.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$396.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$304.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$292.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.00
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$560.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$341.05
|
| Rate for Payer: Health EOS Commercial |
$542.40
|
| Rate for Payer: HFN Commercial |
$560.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$457.08
|
| Rate for Payer: Multiplan Commercial |
$487.55
|
| Rate for Payer: NAPHCARE Commercial |
$365.66
|
| Rate for Payer: Preferred Network Access Commercial |
$560.68
|
| Rate for Payer: Quartz Beloit One Network |
$298.63
|
| Rate for Payer: Quartz Commercial |
$396.14
|
| Rate for Payer: Quartz Medicare Advantage |
$365.66
|
| Rate for Payer: The Alliance Commercial |
$304.72
|
| Rate for Payer: WEA Trust Commercial |
$335.19
|
| Rate for Payer: WPS Commercial |
$451.40
|
|
|
SPLINT NITE FOOT LG NS2000-14
|
Facility
|
IP
|
$586.00
|
|
| Hospital Charge Code |
2975028
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$298.63 |
| Max. Negotiated Rate |
$560.68 |
| Rate for Payer: Aetna Commercial |
$548.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.00
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$560.68
|
| Rate for Payer: Health EOS Commercial |
$542.40
|
| Rate for Payer: HFN Commercial |
$560.68
|
| Rate for Payer: Multiplan Commercial |
$487.55
|
| Rate for Payer: Preferred Network Access Commercial |
$560.68
|
| Rate for Payer: Quartz Beloit One Network |
$298.63
|
| Rate for Payer: Quartz Commercial |
$365.66
|
| Rate for Payer: WEA Trust Commercial |
$335.19
|
| Rate for Payer: WPS Commercial |
$451.40
|
|
|
SPLINT NITE FOOT MED NS2000-12
|
Facility
|
OP
|
$586.00
|
|
| Hospital Charge Code |
2975027
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$170.64 |
| Max. Negotiated Rate |
$560.68 |
| Rate for Payer: Aetna Commercial |
$548.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.12
|
| Rate for Payer: Aetna Managed Medicare |
$170.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$396.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$304.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$292.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.00
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$560.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$341.05
|
| Rate for Payer: Health EOS Commercial |
$542.40
|
| Rate for Payer: HFN Commercial |
$560.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$457.08
|
| Rate for Payer: Multiplan Commercial |
$487.55
|
| Rate for Payer: NAPHCARE Commercial |
$365.66
|
| Rate for Payer: Preferred Network Access Commercial |
$560.68
|
| Rate for Payer: Quartz Beloit One Network |
$298.63
|
| Rate for Payer: Quartz Commercial |
$396.14
|
| Rate for Payer: Quartz Medicare Advantage |
$365.66
|
| Rate for Payer: The Alliance Commercial |
$304.72
|
| Rate for Payer: WEA Trust Commercial |
$335.19
|
| Rate for Payer: WPS Commercial |
$451.40
|
|
|
SPLINT NITE FOOT MED NS2000-12
|
Facility
|
IP
|
$586.00
|
|
| Hospital Charge Code |
2975027
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$298.63 |
| Max. Negotiated Rate |
$560.68 |
| Rate for Payer: Aetna Commercial |
$548.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.00
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cigna Commercial |
$560.68
|
| Rate for Payer: Health EOS Commercial |
$542.40
|
| Rate for Payer: HFN Commercial |
$560.68
|
| Rate for Payer: Multiplan Commercial |
$487.55
|
| Rate for Payer: Preferred Network Access Commercial |
$560.68
|
| Rate for Payer: Quartz Beloit One Network |
$298.63
|
| Rate for Payer: Quartz Commercial |
$365.66
|
| Rate for Payer: WEA Trust Commercial |
$335.19
|
| Rate for Payer: WPS Commercial |
$451.40
|
|
|
SPLINT ORTHO GLASS 2 X 15' #OG-2L2"
|
Facility
|
IP
|
$813.00
|
|
| Hospital Charge Code |
2969540
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$414.30 |
| Max. Negotiated Rate |
$777.88 |
| Rate for Payer: Aetna Commercial |
$760.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$727.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$448.13
|
| Rate for Payer: Cash Price |
$243.90
|
| Rate for Payer: Cigna Commercial |
$777.88
|
| Rate for Payer: Health EOS Commercial |
$752.51
|
| Rate for Payer: HFN Commercial |
$777.88
|
| Rate for Payer: Multiplan Commercial |
$676.42
|
| Rate for Payer: Preferred Network Access Commercial |
$777.88
|
| Rate for Payer: Quartz Beloit One Network |
$414.30
|
| Rate for Payer: Quartz Commercial |
$507.31
|
| Rate for Payer: WEA Trust Commercial |
$465.04
|
| Rate for Payer: WPS Commercial |
$626.25
|
|
|
SPLINT ORTHO GLASS 2 X 15' #OG-2L2"
|
Facility
|
OP
|
$813.00
|
|
| Hospital Charge Code |
2969540
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$236.75 |
| Max. Negotiated Rate |
$777.88 |
| Rate for Payer: Aetna Commercial |
$760.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$727.15
|
| Rate for Payer: Aetna Managed Medicare |
$236.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$549.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$422.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$405.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$448.13
|
| Rate for Payer: Cash Price |
$243.90
|
| Rate for Payer: Cigna Commercial |
$777.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$473.17
|
| Rate for Payer: Health EOS Commercial |
$752.51
|
| Rate for Payer: HFN Commercial |
$777.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$634.14
|
| Rate for Payer: Multiplan Commercial |
$676.42
|
| Rate for Payer: NAPHCARE Commercial |
$507.31
|
| Rate for Payer: Preferred Network Access Commercial |
$777.88
|
| Rate for Payer: Quartz Beloit One Network |
$414.30
|
| Rate for Payer: Quartz Commercial |
$549.59
|
| Rate for Payer: Quartz Medicare Advantage |
$507.31
|
| Rate for Payer: The Alliance Commercial |
$422.76
|
| Rate for Payer: WEA Trust Commercial |
$465.04
|
| Rate for Payer: WPS Commercial |
$626.25
|
|
|
SPLINT ORTHOGLASS 3X12 7344203
|
Facility
|
IP
|
$139.00
|
|
| Hospital Charge Code |
2974632
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$70.83 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.62
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Health EOS Commercial |
$128.66
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.83
|
| Rate for Payer: Quartz Commercial |
$86.74
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: WPS Commercial |
$107.07
|
|
|
SPLINT ORTHOGLASS 3X12 7344203
|
Facility
|
OP
|
$139.00
|
|
| Hospital Charge Code |
2974632
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$40.48 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Aetna Managed Medicare |
$40.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$72.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$69.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.62
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.90
|
| Rate for Payer: Health EOS Commercial |
$128.66
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.42
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: NAPHCARE Commercial |
$86.74
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.83
|
| Rate for Payer: Quartz Commercial |
$93.96
|
| Rate for Payer: Quartz Medicare Advantage |
$86.74
|
| Rate for Payer: The Alliance Commercial |
$72.28
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: WPS Commercial |
$107.07
|
|
|
SPLINT ORTHO GLASS 3x15' #OG-3L2"
|
Facility
|
IP
|
$966.00
|
|
| Hospital Charge Code |
2969537
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$492.27 |
| Max. Negotiated Rate |
$924.27 |
| Rate for Payer: Aetna Commercial |
$904.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$863.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$532.46
|
| Rate for Payer: Cash Price |
$289.80
|
| Rate for Payer: Cigna Commercial |
$924.27
|
| Rate for Payer: Health EOS Commercial |
$894.13
|
| Rate for Payer: HFN Commercial |
$924.27
|
| Rate for Payer: Multiplan Commercial |
$803.71
|
| Rate for Payer: Preferred Network Access Commercial |
$924.27
|
| Rate for Payer: Quartz Beloit One Network |
$492.27
|
| Rate for Payer: Quartz Commercial |
$602.78
|
| Rate for Payer: WEA Trust Commercial |
$552.55
|
| Rate for Payer: WPS Commercial |
$744.11
|
|
|
SPLINT ORTHO GLASS 3x15' #OG-3L2"
|
Facility
|
OP
|
$966.00
|
|
| Hospital Charge Code |
2969537
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$281.30 |
| Max. Negotiated Rate |
$924.27 |
| Rate for Payer: Aetna Commercial |
$904.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$863.99
|
| Rate for Payer: Aetna Managed Medicare |
$281.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$502.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$532.46
|
| Rate for Payer: Cash Price |
$289.80
|
| Rate for Payer: Cigna Commercial |
$924.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.21
|
| Rate for Payer: Health EOS Commercial |
$894.13
|
| Rate for Payer: HFN Commercial |
$924.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$753.48
|
| Rate for Payer: Multiplan Commercial |
$803.71
|
| Rate for Payer: NAPHCARE Commercial |
$602.78
|
| Rate for Payer: Preferred Network Access Commercial |
$924.27
|
| Rate for Payer: Quartz Beloit One Network |
$492.27
|
| Rate for Payer: Quartz Commercial |
$653.02
|
| Rate for Payer: Quartz Medicare Advantage |
$602.78
|
| Rate for Payer: The Alliance Commercial |
$502.32
|
| Rate for Payer: WEA Trust Commercial |
$552.55
|
| Rate for Payer: WPS Commercial |
$744.11
|
|
|
SPLINT ORTHO-GLASS COMFORT PRECUT 3 X 35" 73442-00004-00"
|
Facility
|
IP
|
$389.00
|
|
| Hospital Charge Code |
2972990
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$198.23 |
| Max. Negotiated Rate |
$372.20 |
| Rate for Payer: Aetna Commercial |
$364.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.42
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$372.20
|
| Rate for Payer: Health EOS Commercial |
$360.06
|
| Rate for Payer: HFN Commercial |
$372.20
|
| Rate for Payer: Multiplan Commercial |
$323.65
|
| Rate for Payer: Preferred Network Access Commercial |
$372.20
|
| Rate for Payer: Quartz Beloit One Network |
$198.23
|
| Rate for Payer: Quartz Commercial |
$242.74
|
| Rate for Payer: WEA Trust Commercial |
$222.51
|
| Rate for Payer: WPS Commercial |
$299.65
|
|
|
SPLINT ORTHO-GLASS COMFORT PRECUT 3 X 35" 73442-00004-00"
|
Facility
|
OP
|
$389.00
|
|
| Hospital Charge Code |
2972990
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$113.28 |
| Max. Negotiated Rate |
$372.20 |
| Rate for Payer: Aetna Commercial |
$364.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.92
|
| Rate for Payer: Aetna Managed Medicare |
$113.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$262.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$202.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$194.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.42
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$372.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.40
|
| Rate for Payer: Health EOS Commercial |
$360.06
|
| Rate for Payer: HFN Commercial |
$372.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$303.42
|
| Rate for Payer: Multiplan Commercial |
$323.65
|
| Rate for Payer: NAPHCARE Commercial |
$242.74
|
| Rate for Payer: Preferred Network Access Commercial |
$372.20
|
| Rate for Payer: Quartz Beloit One Network |
$198.23
|
| Rate for Payer: Quartz Commercial |
$262.96
|
| Rate for Payer: Quartz Medicare Advantage |
$242.74
|
| Rate for Payer: The Alliance Commercial |
$202.28
|
| Rate for Payer: WEA Trust Commercial |
$222.51
|
| Rate for Payer: WPS Commercial |
$299.65
|
|
